The clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; however, problem lists are often incomplete and provider attitudes towards the problem list are poorly understood. An ethnographic study of healthcare providers conducted from April 2009 to January 2010 was carried out among academic and community outpatient medical practices in the Greater Boston area across a wide range of medical and surgical specialties. Attitudes towards the problem list were then analyzed using grounded theory methods. Attitudes were variable, and dimensions of variations fit into nine themes: workflow, ownership and responsibility, relevance, uses, content, presentation, accuracy, alternatives, support/education and one cross-cutting theme of culture. Significant variation was observed in clinician attitudes towards and use of the electronic patient problem list. Clearer guidance and best practices for problem list utilization are needed.

/pdf/clinician-attitudes-toward-and-use-of-electronic-problem-dwgqebvicv.pdf

Clinician attitudes toward and use of electronic problem lists: a thematic analysis.

Accurate patient problem lists are valuable tools for improving the quality of care, enabling clinical decision support, and facilitating research and quality measurement. However, problem lists are frequently inaccurate and out-of-date and use varies widely across providers. Our goal was to assess provider use of an electronic problem list and identify differences in usage between medical specialties. Chart review of a random sample of 100,000 patients who had received care in the past two years at a Boston-based academic medical center. Counts were collected of all notes and problems added for each patient from 1/1/2002 to 4/30/2010. For each entry, the recording provider and the clinic in which the entry was recorded was collected. We used the Healthcare Provider Taxonomy Code Set to categorize each clinic by specialty. We analyzed the problem list use across specialties, controlling for note volume as a proxy for visits. A total of 2,264,051 notes and 158,105 problems were recorded in the electronic medical record for this population during the study period. Primary care providers added 82.3% of all problems, despite writing only 40.4% of all notes. Of all patients, 49.1% had an assigned primary care provider (PCP) affiliated with the hospital; patients with a PCP had an average of 4.7 documented problems compared to 1.5 problems for patients without a PCP. Primary care providers were responsible for the majority of problem documentation; surgical and medical specialists and subspecialists recorded a disproportionately small number of problems on the problem list.

Use of an Electronic Problem List by Primary Care Providers and Specialists

The problem list is a critical component of the electronic medical record, with implications for clinical care, provider communication, clinical decision support, quality measurement and research. However, many of its benefits depend on the use of coded terminologies. Two standard terminologies (ICD-9 and SNOMED-CT) are available for problem documentation, and two SNOMED-CT subsets (VA/KP and CORE) are available for SNOMED-CT users. We set out to examine these subsets, characterize their overlap and measure their coverage. We applied the subsets to a random sample of 100,000 records from Brigham and Women’s Hospital to determine the proportion of problems covered. Though CORE is smaller (5,814 terms vs. 17,761 terms for VA/KP), 94.8% of coded problem entries from BWH were in the CORE subset, while only 84.0% of entries had matches in VA/KP (p<0.001). Though both subsets had reasonable coverage, CORE was superior in our sample, and had fewer clinically significant gaps.

Comparative analysis of the VA/Kaiser and NLM CORE problem subsets: an empirical study based on problem frequency.

Effect of implementation of a coded problem list entry subsystem

LAST MONTH THE federal government launched its meaningful use program, based around a set of standards designed to ensure that healthcare providers adopt electronic health records (EHRs) that can produce better health outcomes. One criterion focuses specifically on the problem list and requires eligible providers and hospitals place all patients on a common dictionary through coding. A common dictionary will help facilitate future decision support tools and prepare the problem list for upcoming health information exchange. While a coded platform will be a step in the right direction, it unfortunately will not be enough to create problem lists that fully support the needs of modern medicine. Currently, the content and use of today's problem lists varies widely from practitioner to practitioner, and this diversity can compromise patient care. The future of the problem list needs to move beyond coding to standardization of content and utilization. The problem list was originally created by Lawrence Weed in the 1960s as part of his recommendation for a problem-oriented medical record. 1 A simple idea, the problem list soon became a commonly accepted part of the medical record and is used in most EHRs today. At a high level the problem list states the most important health problems facing a patient. While the basic structure of the problem list varies widely by healthcare organization, at its core, the problem list includes a patient's nontransitive diseases. The problem list offers four major benefits to patient care. In the office, the problem list helps practitioners identify the most important health factors for each patient, allowing for custom-ized care. Beyond the patient visit, the problem list can be used to identify disease-specific populations. It is easy to run data analysis and find all patients with a common illness through coded problems in an EHR. This application can be particularly useful for quality improvement programs. For instance, health centers conducting quality improvement efforts can rely on problem lists to identify their disease-specific patient populations , provide follow-up care, and ensure all patients are receiving care that meets best practices in treatment. The problem list also can be the basis for determining standard measures or report cards in healthcare for both individual practitioners and healthcare institutions. Practitioners and healthcare organizations are often judged by treatment statistics that involve a certain percentage of patients receiving recommended tests and treatments. The problem list can provide the denominator for these statistics. Finally, …

The problem list beyond meaningful use. Part I: The problems with problem lists.

Best practices for problem lists in an EHR.

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Best practices for problem lists in an EHR.